War and the Health of Nations

By Zaryab Iqbal

Assessments of the costs of war generally focus on the financial, political, military, and territorial risks associated with involvement in violent conflict. Often overlooked are the human costs of war, particularly their effects on population well-being. In War and the Health of Nations, Zaryab Iqbal explores these human costs by offering the first large-scale empirical study of the relationship between armed conflict and population health. Working within the influential "human security" paradigm—which emphasizes the security of populations rather than states as the central object of global security—Iqbal analyzes the direct and indirect mechanisms through which violent conflict degrades population health. In addition to battlefield casualties, these include war's detrimental economic effects, its role in the creation of refugees and forced migration, and the destruction of societies' infrastructure. In doing so, she provides a comprehensive picture of the processes through which war and violent conflict affect public health and the well-being of societies in a cross-national context.

War and the Health of Nations provides a conceptual and theoretical framework for understanding the influence of violent interstate and intrastate conflict on the quality of life of populations and empirically analyzes the war-and-health relationship through statistical models using a universal sample of states. The analyses provide strong evidence for the direct as well as the indirect effects of war on public health and offer important insights into key socio-economic determinants of health achievement. The book thus demonstrates the significance of population health as an important consequence of armed conflict and highlights the role of societal vulnerabilities in studies of global security.

• Language: English
• Publisher: Stanford University Press
• Release date: Feb 10, 2010
• ISBN: 9780804773706

Book preview

1

INTRODUCTION

SINCE THE END OF WORLD WAR II, there have been numerous interstate and intrastate conflicts resulting in millions of deaths and billions of dollars’ worth of destruction. Yet scholars have paid very little attention to the consequences of conflict, in particular to its social consequences. The World Health Organization’s (WHO) 2002 World Report on Violence and Health revealed that 1.6 million people die each year due to violence, including collective violence such as conflicts within or between states, and a large number of the people who lose their lives due to militarized conflict are noncombatants. The 25 largest instances of conflict in the twentieth century led to the deaths of approximately 191 million people, and 60 percent of those fatalities occurred among people who were not engaged in fighting (World Health Organization 2002a). One of the most significant effects of war is the toll it takes on the health and well-being of a population beyond the immediate casualties of combat. In this book, I assess the costs of armed conflict by explaining the relationship between armed conflict and public health.

War leads to direct casualties and deaths during combat; violent conflict also results in widespread death and disability among the civilian populations that are affected either as collateral damage or as deliberate targets. For instance, Russia lost 10.1 percent of its population during World War II, Korea lost 10 percent of its population during the Korean War, and Vietnam lost 13 percent of its population during the Vietnam War (Garfield and Neugut 1997). In addition to direct deaths and injuries caused by combat among the military and civilian populations, conflict results in conditions that contribute to the spread of disease and retardation of health care systems, such as the influenza outbreak during World War I, which killed more people than combat-related deaths. The disease and disability during and after armed conflict is often accompanied by states’ inability to meet the public health needs of their populations if their health care infrastructure has been damaged or destroyed. Moreover, wars are associated with the creation of suboptimal health conditions that result in hazards such as famine, epidemics, weapons-induced pollution, lack of clean water, poor sanitation, and general indigence. Consequently, the population is exposed to new health threats without access to proper health care.

Studying the relationship between conflict and health is particularly important in light of the nature of conflicts in the current international system. Most of the recent and ongoing conflicts in the world are civil or intrastate wars that lead to large-scale devastation of a state’s infrastructure since all the fighting occurs on the territory of one state. This amplifies the conditions that deteriorate the health of societies. Civil conflict is also highly likely to result in displacement of people as refugees or internally displaced persons, exposing communities to health menaces. The crisis in Liberia effectively demonstrates the suffering civil war can inflict on a population. In June 2003, as the Liberian capital of Monrovia was engulfed in violence, the city experienced an outbreak of cholera, and within three months, 6,353 cases of cholera had been reported (World Health Organization 2003). The civil war made it impossible for either Liberian authorities or international agencies to carry out the extensive process of water chlorination that could halt further spread of the disease. Moreover, afflicted people were unable to access medical facilities due to the security situation. In September 2003, the WHO reported that only 32 percent of the Liberian population had access to clean water, no more than 30 percent of the population had access to latrines, and there had been no regular garbage collection in Monrovia since 1996. The SKD Stadium, the largest camp for internally displaced people in Monrovia, housed about 45,000 people who cook and sleep in any sheltered spot they can find, in hallways and in tiny slots under the stadium seats, with six nurses in the health center for 400 daily patients (World Health Organization 2003). After the civil war, the life expectancy in Liberia remains 41 years.

Examples of devastating effects of violent conflict on public health abound in recent decades. In the Sudan, prolonged conflict has exposed the population to diseases such as yellow fever, malnutrition, displacement of large groups, poverty, and famine. The Iraqi society experienced near destruction of their health care system, previously one of the best in the Middle East, during the first Gulf War. Public health in Iraq continued on a path of steady decline for a decade of international sanctions and internal repression, after which the general and health infrastructures were subjected to a second war. In 1993, Iraq’s water supply was estimated at 50 percent of prewar levels (Hoskins 1997) and war-related postwar civilian deaths numbered about 100,000 (Garfield and Neugut 1997). In 2006, approximately 2 million people were internally displaced in Iraq (United Nations High Commissioner for Refugees 2007).

For every interstate or civil war, populations of states suffer short-term and long-term effects on their health and well-being. To understand the real cost of violent conflict, it is necessary to take into account the human cost of war. Violent conflict can have economic, social, political, and environmental consequences; yet, while a large number of conflict studies focus on causes of conflict, the literature about the consequences of conflict—and in particular the health consequences—remains relatively scarce. While scholars have examined some aspects of the economic and political consequences of conflict, far less work has been done on the manner in which conflict undermines public health. The effects of conflict on a society continue long after the actual fighting has ceased, and understanding the social consequences of war is integral to estimating the true cost of conflict.

The effect of war on population well-being is closely associated with national and global security. The traditional approaches to studying security focus primarily on state-level factors. The idea of security is generally considered synonymous with protecting the territory and national interests of a state from external aggression or unwelcome interference. Once a state is able to safeguard its military, territorial, and political interests from outside threats, it is perceived to have attained national security. Particularly during the Cold War era, realist notions of security dictated that foreign policy and state leaders remain unrelentingly occupied with the pursuit of military superiority. The emphasis of neorealist theory on states as the single most important entity in the international system led to the deprecation of the interests of sub-state actors. Entities without sovereignty did not warrant attention at the international level, and what occurred within the borders of a sovereign state was to be addressed at the domestic level. Only threats to the security and existence of states were considered detrimental to global security and thus worthy of international attention and action.

In stark contrast to this conventional perspective, the emerging notion of human security considers first and foremost the security of state populations; this perspective asserts that the factors that engender insecurity among the people living within states are not limited to perpetuation of the state. Instead, the security of people is inextricably bound up with their quality of life and, therefore, threats to their security include a range of social and economic issues beyond the territorial integrity of their states. Elements of human security include economic security, political security, access to food and health care, personal and community security, and environmental security (United Nations Development Programme 1994). The occurrence of violent international conflict can adversely affect any or all of these factors and amplify the insecurity of people in the affected state. However, the absence of militarized conflict does not guarantee the elimination of these threats to human security. In order to gain an adequate understanding of whether people—and not merely states—are secure, the various components of human security must be addressed rather than conflating the security of people with the security of their state. The shift from state security to human security is necessitated by the salience and the global nature of the issues that threaten the security of populations. Problems like environmental degradation and disease proliferation do not just threaten the security of people in a single state; these problems can easily reach global magnitude.

Although the literature on the concept of human security offers varying definitions of what constitutes the security of people, there is a clear agreement that health is an important component of security. Human security entails the ability of people to maintain a quality of life that does not fall below the level at which they feel secure. Adequate provision of public health is important in enabling people to achieve a secure quality of life and to be functional enough to maintain their lifestyle. It is the security of populations, rather than states, that makes the world secure. State security is important in that people cannot be secure if the existence of the states in which they live is threatened. However, students of security must go beyond state security to understand the true nature of human security. Violent conflict is accepted as a major threat to the security of states; it is also a formidable threat to the security of state populations. One way in which conflict decreases the security of people is by causing a decline in provision of public health. Since the health of a population is an integral component of the security of communities and individuals, studying the effect of conflict on health is an important contribution to the understanding of human security. And human security, due to its focus on the well-being of populations, is a better framework within which to assess international security than the traditional approach of viewing the security of states as the best indicator of global security.

Studying the relationship between conflict and public health is valuable for scholars, policy makers, practitioners, and the general population. Understanding this relationship adds to the scholarly literature about the consequences of conflict by focusing attention on its effects on public health. A rigorous social scientific exploration of this topic provides policy makers with relevant information for decisions regarding public health, including but not limited to allocation of resources for health purposes. Moreover, a wider knowledge base on this topic would enable health care workers and public health practitioners to develop a clearer understanding of a significant influence on the health of a society and, therefore, to better perform their duties.

The implications of this project have broad relevance due to the interconnectedness of the issues involved in the relationship between conflict and health. The ideas of human security have already become an important force in foreign and domestic policy making. Canada, Japan, Norway, and a number of other states are members of the Human Security Network and are actively incorporating considerations of human security into their policy decisions. An understanding of the effect of war on health would inform the security policies of states as the costs of war become clearer. Just as the financial cost of waging war is taken into consideration before embarking on military action, the health cost—if properly understood—would also be a factor in the decision to go to war. Further, an emphasis on human security and health is likely to influence budgetary trade-offs between defense and social spending. In addition to policy makers at the national level, this study holds relevance for practitioners and international organizations in the realms of security, development, health, and human rights. Health care is closely related to broader issues of development and the effect of conflict on health calls for active participation by humanitarian agencies. Understanding how conflict affects public health serves two chief purposes in the policy/practice arena. First, it enables policy makers and practitioners in national governments and international governmental and nongovernmental organizations to formulate more effective strategies for dealing with humanitarian emergencies as well as long-term health issues, such as disabilities and preventive health care. Second, it illuminates a significant social cost of conflict, making violent conflict less attractive. The higher the projected cost of violent conflict, the more likely states and groups are to seek nonviolent means of conflict resolution. Most important, this study is relevant to the people whose security it addresses. An important element of human security is the empowerment of people to enhance their own security. Comprehending the costs of war influences the perception of war among populations and affects public opinion and decisions regarding political participation.

The academic audience for this study is also wide and diverse. The examination of the effect of conflict on health draws on, and contributes to, the fields of conflict processes, development, economics, and public health. The range of sociopolitical and economic factors involved in assessing the costs and consequences of war reflects the interconnectedness of various academic disciplines in social scientific work. Conflict and security scholars maintain a profound interest in the causes and consequences of war; this study examines an important impact of conflict within a broader framework of security than has been employed in previous work. The close relationships among poverty, development, war, economics, and health extend the scope of this project to development economists and public health scholars. Studying the security of people rather than the security of states calls for an integrative approach in scholarship. Issues of military security of states could be delegated to scholars of war, but the broad and complex nature of human security warrants a multidisciplinary approach. Since this study is based in the human security framework and contributes to the understanding of human security, it holds relevance for scholars in any discipline that deals with issues that influence the quality of life of populations.

The impact of violent conflict on public health disrupts the lives of populations in the immediate and short term by causing death and destruction, and in the medium and long term due to the inability of communities to meet their possibly escalated health care needs. War results in large numbers of deaths among combatants as well as the civilian populations and destroys many aspects of community life that are necessary to meet the health care needs of people. The violence and devastation of war results in destruction of important elements of the infrastructure, as well as in diversion of scarce resources from social and health spending to military expenditures. As violence pervades the society, it becomes an accepted means of resolving issues and leads to domestic violence and increased crime (Levy and Sidel 1997). Hence violent conflict has serious and lasting effects on public health, and this book explores questions regarding the way in which these negative effects occur. Conflict adversely affects public health and the exploration of this relationship in this book makes theoretical and conceptual, as well as methodological, contributions to the disciplines of political science and public health. The question of how conflict affects public health holds interest for both scholars and policy makers, and this work is an attempt to offer a social scientific analysis of the issue.

The main argument in this book is that violent conflict has serious direct and indirect effects on the health of a society and that war undermines the well-being of populations through a range of mechanisms. Militarized violence obviously has a negative effect on the well-being of a society due to death and injury; but war also results in indirect effects on health through decreased efficiency of health care systems, prevalent disabilities among the population, and the spread of disease. History reveals that more soldiers lose their lives due to infectious diseases than through direct armed conflict (Foege 1997). In this book, I explore the multiple dimensions of the war and health relationship and analyze the linkages among armed conflict, political and socioeconomic influences, societal capacities, and population well-being. Below I present an overview of the organization of the book.

As mentioned above, this study is motivated by the human security framework. In Chapter 2, I discuss the concept of human security and argue that this perspective offers a more appropriate approach to the evaluation of global security than the state-centric extant theoretical frameworks employed in the study of international security. I describe the guiding principles behind the concept of human security and propose it as a new paradigm for studying international politics. I discuss the broad and integrative nature of this concept, some definitional and epistemological issues that pose a challenge to social scientific studies of human security, and the implications of this approach for global security. I present health as a core component of human security and provide a discussion of the linkages among human security, war, and public health.

Building on the discussion of human security, I present my conceptual and theoretical framework for studying the relationship between war